There’s a Health Care Crisis in India. Not my words, but those of Jean Drèze and his long-time writing partner, the Nobel-Prize-winning economist Amartya Sen. Compared to other countries in South Asia – and on some indicators, in parts of Sub-Saharan Africa – India’s health indicators are lamentable. In a poor country with massive inequalities, two different kinds of health problems are now facing India. Along with the continuing ‘diseases of poverty’ – notably TB and malaria, and co-infections with AIDS – diabetes, heart disease and cancer have become major threats. Despite the burden of infectious diseases, poor nutritional status and low levels of immunisation coverage for its children, the country wishes to be considered as an emerging economy and to strut its stuff on the world stage.
Do India’s politicians care? It wouldn’t seem so. Public health issues don’t make it onto the discussion pages in the newspapers or onto the rolling TV news programmes. Election manifestoes make for pretty grim reading, and their promises don’t have any weight after the polls have closed, but even they have little to say about health issues. Two health topics have, nevertheless, surfaced for discussion in the past few weeks.
The first is the summary transfer of the Central Government’s Health Secretary – Keshav Desiraju – to the insignificant position of Secretary to the Consumer Affairs Ministry. In a hard-hitting op-ed in the Times of India, Ramachandra Guha, argues that the transfer was at the behest of those in league with the disgraced former President of the Medical Council of India. This Gujarati doctor has been arrested twice for corruption, but has not been found guilty. The corruption charges related to his alleged willingness to smooth the path for new medical colleges to be established. Inspections of existing medical colleges under his presidency have also often been accused of being white-washes, ignoring failures to meet the minimum requirements of staff, hospital beds and so on. Given that many politicians have established medical colleges, and wish to do deals over plans to open many more, Guha’s account – supported by many others who signed a letter to the Health Minister – seems entirely plausible.
The second health news item is Congress Party leader Rahul Gandhi’s support for free medicines for the poor. In the autumn of 2013 he was widely reported lauding the Rajasthan Government’s free medicine scheme. Launched by the Congress Party’s Ashok Gehlot administration in October 2011, it offers a range of free generic medicines at Government health centres. In 2013, the scheme was extended to include some free medical tests. Rahul Gandhi sought to contrast his party’s concern with jobs, food and medicines for the poor with the priorities of the Bharatiya Janata Party [BJP], which, he said, only wanted to build roads and airports. The Congress-led Government in Karnataka is working on similar lines, developing a new health insurance scheme to benefit those deemed to be ‘Above Poverty Line’. But that, and the existing scheme for people ‘Below the Poverty Line’, faces hostility from hospital owners, who fear they will be put out of business by the limits on what they will be allowed to charge.
The Congress Party’s manifesto, due to be released on 21 March, is said to focus on extending a series of rights in the social sector: health, housing, water and sanitation. It promises a framework for a comprehensive guaranteed health service for all citizens. Public expenditure on health stands currently at 1.2 per cent of GDP; according to The Hindu, Congress wants to increase it to 3 per cent if it returns to power. The money would be spent on free medicines and medical tests at government hospitals, and health care centres; a National Health Insurance Programme for all, with cashless prepaid insurance; a National Health Mission covering both urban and rural areas; five mobile health care vans for each of the 640 districts in the country; and creation of six million jobs in the sector by 2020.
By contrast, the BJP’s approach focuses much more on enlisting the private sector’s support to improve the quality of life and infrastructure. Its manifesto has yet to be released, and there are few leaks on what it might contain. But it is likely to continue to support the commercialization of health – one of the key contributors, according to Drèze and Sen, to India’s poor health indicators. The Aam Aadmi Party – surprise victors in December’s elections in Delhi State – joined the bandwagon of promising new and better hospitals and clinics, along with better access to Ayurveda, Naturopathy, Homeopathy and Unani medical systems. Their single point that addressed public health issues talked of attacking pollution, contaminated water supplies and poor waste disposal arrangements.
Meanwhile, the everyday politics of ‘health’ also continues to ignore public health and instead to focus on charges of corruption, inter-group identity politics in postings and employment, or complaints about the medical care available to the rich. Revealing of the everyday politics of health in north India is the embarrassment to the Samajwadi Party’s [SP] Government in Uttar Pradesh, who faced a 6-day hospital doctors’ strike earlier this month. 24 junior doctors were arrested in Kanpur after clashing with SP MLA Irfan Solanki and his supporters at the end of February. Kanpur Medical College is notorious for being dominated by right-wing Hindu interests; Solanki is a Muslim.
So what can India’s people expect on the health front from May’s election results? Precious little, in reality. Firstly, health is a matter for State governments, so regime change in Delhi may have little effect on what goes on in the country. Secondly, for all their grand promises, Congress – the only party with a substantial health agenda – has failed to deliver very much where it counts (in the large, poor, north Indian States) in the 10 years of its coalition rule. Thirdly, improvements in health indicators may have rather little to do with specifically ‘health’ policies. Education, food availability, employment guarantees and some life-style changes might be more important. Nonetheless, bringing issues of health and health care ‘much closer to the centre of attention in democratic politics,’ as Drèze and Sen put it, would be good: it’s just not likely to happen soon.
Roger Jeffery is Professor of Sociology of South Asia at the University of Edinburgh, and directs its India Institute. He has written on issues of health in India since the 1970s; his book The Politics of Health in India (University of California Press) appeared in 1988. He is currently working on a new book, tentatively called The Transformation of India’s Health System, 1980-2015, as a Fellow at the Institut d’Etudes Avancées de Nantes.